1. Patient Safety Awards 2011 Improving the safety of administration of Emergency Oxygen in adult patients across the UK The BTS guideline for emergency oxygen use in adult patients

2. Oxygen is the most commonly used drug in emergency medicine 34% of emergency ambulance patients receive oxygen Oxygen is used in about 2 million ambulance journeys in the UK each year

3. Oxygen in Hospital 17.5% of UK hospital patients are receiving oxygen at any given time About 18,000 people every day More than 2 million per year

4. Oxygen saves lives but too much may cause death Essential in severely ill patients with low blood oxygen levels Too much oxygen may cause 2,000-4,000 avoidable deaths per year in chronic obstructive pulmonary disease flare ups Too much oxygen is linked to increased risk of death in strokes, ICU patients and survivors of cardiac arrest

5. Chaos reigned until 2008 Most patients were given too much oxygen And there was disagreement about how much oxygen to give Oxygen was rarely prescribed 68% of UK hospital patients who were using oxygen in 2008 had no prescription and most prescriptions were incomplete Doctors and nurses had very little knowledge about safe use of oxygen North West oxygen guideline 2000

6. Time To Do Something Key Theme Safe oxygen for all patients in UK Solution needed to be: »Ambitious »Pioneering »Multidisciplinary

7. Solution – Novel Guideline Early pilots in Salford and Southend BTS appointed Salford and Southend Co- Chairs in 2003 to produce UK Guidance Guideline development group undertook evidence review 2003-04 Universal participation - 21 other societies and colleges

9. Solution – Novel Guideline Early pilots in Salford and Southend. BTS appointed Salford and Southend Co- Chairs in 2003 to produce UK Guidance. Guideline development group undertook evidence review 2003-04 Universal participation - 21 other societies and colleges Draft Guideline prepared 2005-2007 Pilot work continued in Salford/Southend

10. UK Emergency Oxygen Guideline published 2008

11. Doctors prescribe a “target range” and nurses adjust equipment and flow rates to achieve the desired target range Aim at a lower level for (88-92%) for those at risk from higher doses of oxygen Aim for a normal oxygen saturation level for most patients (94-98%) Oxygen is a treatment for low oxygen (Hypoxemia) (Giving oxygen does not relieve breathlessness or increase the oxygen supply to vital organs if the patient’s oxygen level is normal to start with) Key Principles

12. Oxygen Alert Card Safeguards COPD patients who are most at risk from oxygen poisoning

13. “They gave me a card because I’m intolerant of too much oxygen. They used to whack up the oxygen in the ambulance on the way to hospital.”

15. “Last time I was admitted they didn’t turn the oxygen up too high” “I think it is a good thing, it stops them poisoning me with too much oxygen because I mustn’t have too much.”

16. Implementation and Dissemination from Guideline to patient No point in having guideline recommendations if they are not implemented for patient safety Included as integral part of guideline – this is unique

17. Implementation from Guideline to Patient All patients receive correct and safe oxygen Monitoring Nurses must be able to change oxygen being given Doctors must prescribe Need Local Oxygen Policy Need Training

18. Online appendix of Guideline includes implementation materials Summary of recommendations Sample local oxygen policy Patient information sheet (developed with patients) Example of new prescription chart

19. DRUG OXYGEN (Refer To Trust Oxygen Policy) Circle target oxygen saturation 88-92% 94-98% Other___ STOP DATE Starting device/flow rate________ PRN / Continuous PHARM (Saturation is indicated in almost all cases except for palliative terminal care) SIGNATURE / PRINT NAMEDATE ddmmyy Oxygen prescription Model for oxygen section in hospital prescription charts Tick if saturation not indicated

20. Online appendix of Guideline includes implementation materials Summary of recommendations Sample local oxygen policy Patient information sheet (developed with patients). Example of new prescription chart Example of new monitoring chart

21. Respiratory Rate, Oxygen saturation and oxygen therapy Clinical review required if saturation is outside target range Continuous Oxygen / PRN / Not on oxygen therapy Target range: 88-92% 94-98% Other_____ Respiratory Rate Respiratory Rate Oxygen Saturation % Oxygen Saturation % Oxygen Device or Air Oxygen Device or Air Oxygen flow rate L/min Your Initials* Your Initials* Model for respiratory section of observation chart Codes for recording oxygen delivery on observation chart A Air. (Patient not requiring oxygen therapy) AX Measurement on air for a patient who is on PRN Oxygen therapy AW Measurement on air for a patient who is being weaned off oxygen but not yet discontinued on chart N Nasal Cannulae SM Simple mask V24 Venturi 24% V28 Venturi 28% V35 Venturi 35% V40 Venturi 40% V60 Venturi 60% H28 Humidified oxygen at 28% (“Quatro” or similar device) (also H 35, H40, H60) RM Reservoir Mask TM Tracheostomy Mask CP Patient on CPAP system NIV Patient on NIV system OTH Other device *All changes to oxygen delivery systems must be initialled by a registered nurse or equivalent If the patient is medically stable and in the target range on two consecutive rounds, report to a registered nurse to consider weaning off oxygen (unless the oxygen prescription is part of a timed protocol

22. Online appendix of Guideline includes implementation materials Summary of recommendations Sample local oxygen policy Patient information sheet (developed with patients). Example of new prescription chart Example of new monitoring chart Lecture for Doctors Education materials for nurses – unique drop-in training

23. Online appendix of Guideline includes implementation materials Summary of recommendations Sample local oxygen policy Patient information sheet (developed with patients). Example of new prescription chart Example of new monitoring chart Lecture for Doctors Education materials for nurses – unique drop-in training All of these were piloted at Southend and/or Salford

24. Implementation and Dissemination Oxygen Champions Pilot sites illustrated importance of local champions BTS asked for volunteer medical and nursing/physiotherapy oxygen champions in every trust responsible for: Introducing local oxygen policy Organising training for nurses and doctors Conducting audit

25. Launch of Guideline October 2008 PR company helped with pre-launch information to medical press Editorials in journals e.g. Nursing Times, BMJ Letters to Chief Executives Oxygen champions primed: Discussion area on BTS web site Lectures at many National and Regional Meetings

26. Implementation and Dissemination Incorporation of Emergency Oxygen Guidelines in other Guidelines Advantage of Partnership JRCALC (Joint Royal Colleges Ambulance Liaison Committee) Oxygen Guideline April 2009 European Resuscitation Guideline 2010 Resuscitation Council (UK) Guideline 2010 NICE Guideline for Chest Pain of Recent Onset – March 2010 BTS Pneumonia Guideline 2009 BTS-SIGN Asthma Guideline 2011

27. National Patient Safety Agency Rapid Response Report – September 2009 281 reports of serious incidents involving poor oxygen management: Caused 9 deaths May have contributed to 35 further deaths

28. National Patient Safety Agency Rapid Response Report – September 2009 Immediate Actions Oxygen must be prescribed in all situations in accordance with BTS guideline Pulse oximetry should be available in all locations where oxygen is used

29. BTS 2008 and 2010 Oxygen Audits HospitalsPatientsWardsOn O 2 (%) O 2 Prescribed Drug rounds signed Oximetry recorded Correct delivery system 20089914,83071217.532%5%94%47% 20109022,017102615.556%16%99%59%

30. Implementation Audits Feb 2009, November 2010 Feb 2009 n=72 Oct-Nov 2010 Provisional Data n=51 Oxygen Policy in place6%37% Pre-printed oxygen prescription charts 9%51% Pre-printed monitoring chart 7%33% Nurse training fully implemented 7%18% Doctor training fully implemented 4%11%

31. Improvement in prescribing oxygen at Southend

32. BTS Audit supported by NCAAG National Clinical Audit Advisory Group BTS Emergency Oxygen Audit is in the list of audits recommended by the NCAAG for inclusion in Quality Accounts for 2010/2011 Hospitals’ results will be published

33. Moving Forward BTS e-learning programme Oxygen spend down 10% - Target Chief Executives – QIPP Programme BTS Oxygen Champion – Yearly Prize Refine BTS audit results so individual wards/doctors given results Review guidelines; new Paediatric section

34. Moving Forward Guideline group expecting substantial yearly improvements in use of emergency oxygen across UK Safer and better care for all patients receiving Emergency Oxygen Saving Lives